Section 1367.62 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1367.62
. (a) No health care service plan contract that is issued,
amended, renewed, or delivered on or after the effective date of the
act adding this section, that provides maternity coverage, shall do
any of the following:
(1) Restrict benefits for inpatient hospital care to a time period
less than 48 hours following a normal vaginal delivery and less than
96 hours following a delivery by caesarean section. However,
coverage for inpatient hospital care may be for a time period less
than 48 or 96 hours if both of the following conditions are met:
(A) The decision to discharge the mother and newborn before the
48- or 96-hour time period is made by the treating physicians in
consultation with the mother.
(B) The contract covers a postdischarge followup visit for the
mother and newborn within 48 hours of discharge, when prescribed by
the treating physician. The visit shall be provided by a licensed
health care provider whose scope of practice includes postpartum care
and newborn care. The visit shall include, at a minimum, parent
education, assistance and training in breast or bottle feeding, and
the performance of any necessary maternal or neonatal physical
assessments. The treating physician shall disclose to the mother the
availability of a postdischarge visit, including an in-home visit,
physician office visit, or plan facility visit. The treating
physician, in consultation with the mother, shall determine whether
the postdischarge visit shall occur at home, the plan's facility, or
the treating physician's office after assessment of certain factors.
These factors shall include, but not be limited to, the
transportation needs of the family, and environmental and social
risks.
(2) Reduce or limit the reimbursement of the attending provider
for providing care to an individual enrollee in accordance with the
coverage requirements.
(3) Provide monetary or other incentives to an attending provider
to induce the provider to provide care to an individual enrollee in a
manner inconsistent with the coverage requirements.
(4) Deny a mother or her newborn eligibility, or continued
eligibility, to enroll or to renew coverage solely to avoid the
coverage requirements.
(5) Provide monetary payments or rebates to a mother to encourage
her to accept less than the minimum coverage requirements.
(6) Restrict inpatient benefits for the second day of hospital
care in a manner that is less than favorable to the mother or her
newborn than those provided during the preceding portion of the
hospital stay.
(7) Require the treating physician to obtain authorization from
the health care service plan prior to prescribing any services
covered by this section.
(b) (1) Every health care service plan shall include notice of the
coverage specified in subdivision (a) in the plan's evidence of
coverage for evidences of coverage issued on or after January 1,
1998, and except as specified in paragraph (2), shall provide
additional written notice of this coverage during the course of the
enrollee's prenatal care. The contract may require the treating
physician or the enrollee's medical group to provide this additional
written notice of coverage during the course of the enrollee's
prenatal care.
(2) Health care service plans that issue contracts that provide
for coverage of the type commonly referred to as "preferred provider
organizations" shall provide additional written notice to all females
between the ages of 10 and 50 who are covered by those contracts of
the coverage under subdivision (a) within 60 days of the effective
date of this act. The plan shall provide additional written notice of
the coverage specified in subdivision (a) during the course of
prenatal care if both of the following conditions are met:
(A) The plan previously notified subscribers that hospital stays
for delivery would be inconsistent with the requirement in
subparagraph (A) of paragraph (1) of subdivision (a).
(B) The plan received notice, whether by receipt of a claim, a
request for preauthorization for pregnancy-related services, or other
actual notice that the enrollee is pregnant.
(c) Nothing in this section shall be construed to prohibit a plan
from negotiating the level and type of reimbursement with a provider
for care provided in accordance with this section.